Sciatica

Sciatic refers to pain along the course of the Sciatic nerve which travels along the back of the leg. The Sciatic nerve is the largest nerve in the body and originates from the spinal cord. Another related diagnosis is Radiculopathy which means nerve dysfunction. The diagnosis is very common but somewhat inaccurate in name. Since Sciatica refers to a painful nerve, it does not indicate the etiology or the source of the problem. The most common reason a person has Sciatica is a herniated lumbar disc. Other causes of Sciatica could be degenerative disc disease, Spinal Stenosis, and Spondylolisthesis. Initially the pain may be so debilitating that it would prevent the patient from walking. However, some patient may only experience mild to moderate symptoms which could be relieved by simple over the counter medications. Since the nerve originates from the spinal cord, the perceived pain could be in the buttocks or radiate further down to the foot. Pain may not be the only symptom present, but weakness or numbness may also accompany the pain.

Even though the condition may be very painful, permanent damage is uncommon when the only symptoms are pain. Many physicians will categorize patients with motor weakness as more sever dysfunction. The concern with weakness is the possible permanent dysfunction and slow recovery. In treating sciatica the slowest return of function is related to sensation, followed by weakness, and lastly is pain. Most cases are treated electively except in cases which are caused by large herniated discs that lead to bowel and bladder dysfunction. When these cases are accompanied by low rectal tone, and numbness in the anal area, emergent decompression is performed in an attempt to preserve these important functions. This situation is referred to as Cauda Equina Syndrome.

Patients with this condition typically stand with a flexed position of knee and hip. Patients may also bend their body toward the affected side. All these maneuvers attempt to shorten the length of the nerve to reduces the tension on the Sciatic nerve and reduces the pain. Two commonly performed tests performed at diagnosis are the straight leg raising and the Leasuge test. Both have the same concept of stretching the nerve and reproducing the pain. The Bowstring test is performed by palpating the nerve in the back of the knee thereby tensing the nerve and reproducing the pain. Even though the initial diagnosis is made by history and clinical exam, confirmatory tests are performed to ensure diagnosis. The most common test performed is the MRI, followed by a Myelogram, and finally the CT Scan. It is common to combine the Myelogram with the CT scan to increase the accuracy of these tests. Other test available is the CT Discogram which has a lower yield of information and is an invasive test. CT Discograms are good tests to confirm discogenic pain or internal disc derangement.

From numerous studies we now know that motor and sensory dysfunction is produced by pressure over the nerve. Pain is generated not by pressure alone, but the accompanied inflammation. For this reason Anti-inflammatory medications such as Motrin can reduce the pain. Follow-up research indicates that most patients will relieve their symptoms within 6 weeks. The resolution of these symptoms could be promoted using several non-operative modalities. The most common treatment is the use of medications such as Non-Steroidal Anti-Inflammatory (NSAID) medications. These include several over the counter medications like Motrin or Aleve. More powerful drugs are dispensed by prescription only and are prescribed by your physician. These include Arthrotec, Naprosyn, Feldene, or the new COX-2 inhibitors like Celebrex and Vioxx. All have risks and benefits of use and will be discusses prior to their dispense. Since steroids are the most powerful anti-inflammatory medication available they could be used in more sever cases especially when there is motor weakness. Narcotic medications and muscle relaxants are used in more sever cases but are used for a short period only. Physical therapy is commonly used to expedite the healing process and avoid future recurrences. Techniques used promote endurance training, muscle strengthening, pelvic postural stabilization, and generalized physical conditioning. The McKenzie and Williams techniques are used and both have shown improvement of symptoms. Many other modalities such as chiropractic and acupuncture have shown promise in the treatment of sciatica and many patients report improvement of symptoms. However, it is still not completely understood weather these modalities or the natural healing powers of the body are responsible for the recovery. It is wise to assume that both of these factors have a role in the healing process.

In cases that the above modalities did not bring relief, Epidural Steroid Injections may prove beneficial. This technique delivers higher concentration of steroidal medications directly at the area of pressure. Reduced inflammation decreases swelling and indirectly creates more room for the nerve with improvement of symptoms. Routinely the injections are performed three times each one week apart from each other. They are performed sterilely under fluoroscopic guidance to maximize accuracy with the lowest risk of infection.

Minority of patients will not obtain relief from the above treatment modalities and will resort to surgical treatment. The decision to proceed with surgery should be made with your physician after all the information is analyzed. Consideration for surgery should be made on a case to case basis realizing that each patient situation is different. Surgical options are the most invasive forms of treatment, but in the correct circumstances could be the most effective, expeditious, and safe modality. In most cases, symptoms are relieved immediately after surgery and return of function is much faster than non-operative treatment. Pain is the fastest to resolve, followed by motor weakness, and lastly is sensation. The latter two functions may not return as quickly or not at all. The traditional operation was open laminectomy followed by the commonly performed Laminotomy. In the recent years several alternatives have developed including minimally invasive surgery. These include the laser discectomies and the Micro-Endoscopic Discectomies. Each with their own specific success rates, complication rates, and unique benefits. Currently the best overall results are obtained with Micro-Endoscopic Discectomies. This is due to the very small incision needed to remove the disc, and the effective removal of the disc which is similar to the open procedures. Many still claim that laser removal has similar results, but this technique is loosing popularity due to the incomplete resolution of symptoms. Some physicians still advertise this technique similar to Info-Mercials seen on TV for kitchen appliances, but one must keep in mind that miracles are rare in medicine and can not replace sound clinical judgment, knowledge, and test of time. Lasers have not yet gained the confidence of many spinal surgeons in regards to disc herniations to completely relieve the symptoms and so these procedures are performed only by few surgeons believing is unsubstantiated data which can not be reproduced by others. Furthermore, laser probes that are inserted percutanously place the nerve in danger of permanent injury that is higher than other techniques available.